The next frontier

New medical technologies in the valley are fighting cancer, saving hearts and eliminating chronic pain

Radiosurgery

Las Vegas CyberKnife at Summerlin

When surgery on a cancer tumor is difficult, complicated or even impossible, doctors can now operate from the outside — with a powerful, focused beam of radiation.

Maybe it was just part of getting old, Rick Lichty thought. The 63-year-old retiree who split his time between Kansas City and Las Vegas had been feeling tired lately. “I thought it was normal aging, the way I was losing stamina. To get through a normal day, I’d started taking naps. I’d never taken naps.”

A visit to his urologist in Kansas revealed the source of his creeping sense of fatigue: He was diagnosed with prostate cancer. Lichty wasn’t dumbstruck by the news; he’d done his homework. He had a pretty good idea that prostate cancer wasn’t rare (in fact, it’s the second most common cancer in males after skin cancer, striking one in seven men in America). His brother had been diagnosed with it. But the proposed course of treatment gave him pause. His doctor recommended a prostatectomy — removal of Lichty’s entire prostate, a not uncommon recommendation in cases of prostate cancer. Pondering what a full prostate removal might entail — common side effects such as impotence and urinary incontinence, the long tail of recovery from surgery — Lichty must have stepped into the elevator like a man in a trance.

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Lucky he got into that elevator. There he met an elderly man who told him about a decidedly different type of cancer surgery he’d recently had. It sounded to Lichty more like science fiction than medical tech: A high-precision radiation beam that destroyed tumors without hurting healthy tissue — a procedure that didn’t require cutting open his body or removing entire organs. A little Googling revealed that there was just such a piece of radiosurgery technology in Las Vegas called CyberKnife.

Basically, there are three ways to deal with cancer: You can cut it out, poison it, or destroy it with radiation. Radiation therapy has been around for more than 100 years, but it’s come a long way from the days of X-ray treatments and radium baths. Today, it’s leveraging advances in robotic technology and powerful software imaging to bring new levels of precision to treatment in a field called radiosurgery.

Destroy tumors, not tissue

And precision is crucial when it comes to radiosurgery. “The challenge is to destroy tumors, not tissue,” says Dr. Dan Curtis, radiation oncologist at Las Vegas CyberKnife at Summerlin. Older, less precise methods of radiation therapy involve moderate doses of radiation over long schedules; the idea is to kill the cancer tumor without giving the surrounding healthy tissue too big a radioactive dose, while allowing the body to recover between treatments. Compared to older radiation treatments, “CyberKnife is like a sniper rifle versus carpet bombing,” says Dr. Muhammed Ozeroglu, CyberKnife of Las Vegas’ medical physicist. In a hypothetical case of lung cancer, a course of traditional radiation therapy could take seven weeks. CyberKnife could do it in three days, delivering twice the biologically effective radiation dose. That power and precision have also made it an increasingly popular alternative to tumor-removal surgery, particularly when the tumor is near sensitive organs. Today, there are 300 CyberKnife systems operating around the world, and they’ve treated 320,000 patients. “Clinical trials are ongoing, and new articles about the use of radiosurgery are coming out every month,” says Curtis. In other words: The medical establishment is only starting to discover CyberKnife’s place in the cancer-fighting arsenal.

CyberKnife isn’t a cancer cure-all, and at least in America, surgery is still the first go-to option for many tumors. “But with CyberKnife, I’m treating things I couldn’t or wouldn’t treat 15 years ago,” says Dr. Curtis.

‘I had no idea’

CyberKnife uses software imaging to make detailed computer models of tumors, and can lock on to them in real time, an important factor when the patient moves, breathes, or if the tumor itself is moving (it’s a common occurrence). Once locked on, CyberKnife’s robotic arm fires a powerful X-ray, as narrow as a tenth of a millimeter wide, at the tumor, repeatedly attacking it from different angles. The precision lessens the impact on healthy tissue, allowing for a high, destructive radioactive dose; being able to fire at the tumor from multiple vantage points means the beam isn’t repeatedly passing through the same portions of healthy tissue. This makes the course of treatment dramatically shorter.

In his case, Lichty went to the clinic for a week, an hour a day. “They had a pre-made cradle that fit my body (to manage movement), and then I put on some headphones with music, and when it was all done, I felt nothing.” (Traditional radiation therapy for prostate cancer could have taken more than 45 days of daily radiation treatments.)

About two weeks after his final treatment, Lichty noticed something. “I noticed a significant change in my energy levels,” he says. “After two months, I felt like I was 40 again.” Today he’s back to his bike rides and daily walks. “I had no idea how much the cancer had zapped my energy.” His latest blood tests reveal that the cancer is making a fast retreat. Andrew Kiraly

Peripheral nerve surgery

Dr. Tim Tollestrup

“Nobody’s ever looked at the peripheral nerves and said, ‘All these different kinds of chronic pain are out there that linger and cause people huge problems, and they end up on drugs — do the peripheral nerves have something to do with their pain? And if so, are there things that could be done surgically to relieve it?’ That’s the new frontier in peripheral nerves, and that’s the type of surgery that I do.”

When 36-year-old Shaun Plummer stands up to say hello, you can’t help but think of Dwayne “The Rock” Johnson: Not only the close-cropped dark hair, intense eyes and easygoing smile, but also the towering height and arms as big as a pro cyclist’s legs. It’s tough to imagine someone so powerful lying on his couch for seven months, unable to sit or stand up for more than a few minutes. Yet that’s what happened to Plummer in the fall of 2013.

“I just started having weird shocks, like nerve shocks down my left leg,” he says. “I didn’t really say anything at first, because I could still work and mostly do what I needed to do, and then one day, it hit and it didn’t really go away. I went to work, and I just had to go home.”

In retrospect, Plummer says, the pain had been there for a few years, slowly getting worse. He was a bartender then, on his feet all day, so it was particularly disruptive. Even his side occupation, poker, was difficult, because it involved sitting for long periods. Going to the gym was out of the question.

The first doctor Plummer saw was a neurologist, who looked at Plummer’s MRIs and determined he had a slightly herniated disc that was pinching his left sciatic nerve root. The largest and longest nerves in the body, the sciatics begin in the low back and run separately down through the left and right buttocks and back of each leg.

“They told me to go get some rest and go back to work,” Plummer says. “And I was like, okay … But I didn’t go back to work — I couldn’t. And they didn’t figure it out for a few months.”

Exasperated, Plummer and his friends took to the Internet and eventually stumbled on piriformis syndrome, named for a muscle in the buttock that goes right over the spot where the sciatic nerve winds its way from the spine through the pelvis. This muscle can get pulled, be unusually tight or otherwise compress the sciatic nerve, inflaming it. The sharp, nagging pain that results sounded exactly like what Plummer had.

The neurologist doubted his self-diagnosis, telling him piriformis syndrome was rare, but he did agree to another MRI focused on the pelvis. Lo and behold, the piriformis muscle on Plummer’s left side was 50 percent larger than the one on the right. He didn’t need a neurologist; he needed a peripheral nerve surgeon. He needed Tim Tollestrup.

Pain in the butt

What Shaun Plummer went through is unfortunately common, according to Tollestrup. It’s not the fault of the neurologists, orthopedists and others who misdiagnose the source of their patients’ pain. It’s the way medicine is taught.

“No doctors are given any kind of meaningful education about either the anatomy of the peripheral nerves or the way in which peripheral nerve problems present,” Tollestrup says. “Therefore, all the chronic pain due to that is like a black box to medicine.”

Neurosurgeons operate on the brain and spinal chord; orthopedic surgeons who specialize in the neck and back focus on the vertebral column. Once the nerves leave that central corridor, they fall under the jurisdiction of whichever surgeon specializes in the nearest body part — say a hand surgeon for carpal tunnel syndrome, or a foot/leg specialist for femoral nerve issues.

Until recently, there had been no specialty for the peripheral nerve system, per se. Lee Dellon changed that when he founded the Dellon Institutes for Peripheral Nerve Surgery in 2000, seven years before Tollestrup did his fellowship there and found his professional passion.

“The traditional field of peripheral nerves was geared toward restoring function or repairing motor nerves that have been damaged,” Tollestrup says. “The focus of what I do is geared toward chronic pain.”

Tollestrup’s surgical method is simple: He either alters the patient’s anatomy to remove the cause of nerve compression (the piriformis muscle, in Shaun Plummer’s case); or he disconnects or reroutes the nerve itself. But there’s a complicated part, too: Finding the right nerve. It requires an intimate knowledge of nervous system anatomy and detective-like diagnostic skills. Tollestrup spends lots of time listening to patients and parsing the subtleties of their experience.

“Patients know their own bodies,” he says. “Often times, they know there’s a problem, but their doctors just can’t figure it out.”

Straight-up guy

Plummer says there was no hard sell, just Tollestrup’s findings and opinions. By that point, he’d been immobilized by his pain for more than half a year, so surgery was an easy decision. Tollestrup removed 80 percent of Plummer’s piriformis muscle to reduce the compression on his sciatic nerve. Within six weeks, Plummer was back tending bar. Not long after, he gave it up to play poker full-time — not because of pain, he says, but because he was just tired of bartending after 15 years.

He’s back in the gym now and says he can do almost anything, physically, he could before except exercises that work the lower abs, like hanging leg lifts. His chronic pain is gone, though he does sometimes feel a ghost of it.

Still, Plummer says, the surgery changed everything for him. “I couldn’t sit or stand up. I mean, I could have lived, but that would have been a weird life.” Heidi Kyser

Cardiac cryoablation

Dr. Dhiraj Narula, HealthCare Partners

Irregular heartbeats afflict millions of Americans, and can lead to strokes and heart attacks. Medications only work half the time. Now a cool new idea — literally — is offering patients hope.

The first time Angel Lynch’s heart went crazy, she was driving. “I started to feel lightheaded, dizzy, short of breath, and my vision started going blurry.” Fearing she might crash, she pulled over and called her husband to pick her up and take her straight to the emergency room.

Lynch was experiencing a kind of irregular heart rhythm episode called atrial fibrillation. “It’s like your heart is flapping and fluttering, your whole chest is pounding and you can feel it in the back of your throat, taking away your breath,” says 37-year-old Lynch. “You’re so used to your heart doing what it needs to do, you take it for granted. So it’s really scary when it happens.” (Perhaps ironically, at the time, Lynch was completing her studies to become a nurse.)

If you think of the four chambers of the heart as a well-tuned percussion troupe, in atrial fibrillation, the top two chambers lose the beat — and then tear off into their own raging drum solo. Triggered by electrical misfires, the two upper chambers start beating erratically, chaotically, randomly, throwing off the heart rhythm and thus the body’s entire blood flow. Atrial fibrillation (aka AFib) can cause strokes or heart attacks. It affects 3 million Americans, according to a 2005 figure by the Cleveland Clinic, and the number is expected to increase to 8 million by 2050. AFib can be due to a genetic predisposition — as in the case of Lynch — but it’s also associated with obesity, high blood pressure and diabetes.

“It was to the point that I didn’t want to drive with my kids in the car, I was so scared,” Lynch says. “I had no control over when it came on, how long it lasted. What if I blacked out with the kids in the car and crashed?” Officially diagnosed in 2012, Lynch went on medications in an attempt to quell the atrial fibrillation episodes. She got mixed results. The condition retreated somewhat, but the meds sometimes made her lightheaded or groggy — not unlike some of the symptoms of atrial fibrillation itself. And even prescription pills couldn’t stop every episode of irregular heartbeat. By 2014 — her condition muted, but not cured, by medication — she had begun working as an RN at HealthCare Partners medical clinic. She ended up working for the very doctor who would hopefully hold the key to stopping her AFib for good.

‘Like a ball of ice’

Atrial fibrillation is an electrical problem with the heart, and medications for AFib target various parts of the cardiovascular system. Beta blockers such as Carvedilol or Propranolol slow the heart rate down. Channel blockers such as Flecainide or Amiodarone aim to regulate the heart’s electrical signals. However, meds only have a roughly 50 percent success rate of controlling AFib, and side effects can range from dizziness and nausea to scarring of the lungs. In 1998, French scientists determined that AFib starts in one of the four veins that carry blood from the lungs to the heart’s left atrium. The next step was developing the use of radiofrequency heat to selectively destroy tissue around these veins, thus disrupting their ability to conduct the misfired electrical blips that cause AFib — short-circuiting the short circuit, as it were. Today, the idea of selectively damaging heart tissue has gone cold — literally — with a new process called cardiac cryoablation.

“The idea is to stop the electricity, but keep the blood flowing,” says Dr. Dhiraj Narula, cardiologist at HealthCare Partners. And cardiac cryoablation is thought to do this more effectively than radiofrequency ablation. Radiofrequency ablation involves making dozens of individual burns — imagine the tip of a catheter wand cauterizing the inner walls of the pulmonary veins, one dot at a time. Cryoablation involves reaching the vein and then inflating inside it a balloon with nitrous oxide cooled to a temperature of 40 degrees. Cryoablation essentially destroys the heart tissue — and therefore disrupts those errant signals — one entire circle at time — “like a ball of ice,” says Narula.

“The cold makes it stick,” explains Narula. “It creates a much more durable lesion.” And that, he says, means that a patient who undergoes cardiac cryoablation is less likely to start experiencing irregular heartbeats again. Narula says the success rate for cardiac cryoablation is about 80 percent. He was among the first doctors in the Las Vegas Valley to start using technique, performing his first procedure in 2012 with the help of visiting doctor Dr. Mike Bensler. Since then, Narula has performed 130 cardiac cryoablations.

“I mean, just imagine what a chest X-ray was, just one picture with overlapping shadows and stuff. And then you had the CT scan, and that basically takes (pictures in) slices through the chest, so you could see everything separately… In three years, there will be no more 2-D. It’ll all be 3-D.”

— David Steinberg, managing partner of SDMI

Heart at rest

One of the hard parts to diagnosing AFib is that it can be hard to catch in the act — the panicky, fish-flopping-in-your-ribcage feeling can last a few minutes and then disappear. To get a better understanding of Lynch’s AFib, Narula outfitted her with a small heart monitor. She was still experiencing occasional heart flutters and flops despite her regimen of meds, and eventually decided to undergo cardiac cryoablation in February.

“I was the biggest baby going into that room,” says Lynch, noting that her nervousness was irrational, knowing Dr. Narula from working with him and seeing him work. “My heart was literally in his hands, and I put so much trust in him.”

The surgery was a success. She was on a short, transitional course of anti-AFib meds after the surgery, but Lynch has been off meds for six weeks now and hasn’t had an irregular heartbeat episode since. This probably says it all: For this interview, she’s talking on the phone from San Diego, where she drove the family for a vacation.

“I don’t have to worry where the closest hospital or urgent care is, there was no stress or anxiety driving here. I feel more at peace and more secure, and I just feel I don’t have to worry so much for my children.” Her heart is finally at rest. Andrew Kiraly

Full-body makeover

Dr. Himansu Shah

“The first and biggest challenge is to lose the weight, and then, as you lose the weight, you realize that you are not liking your body as it appears with all the (excess) flabby and sagging skin. In the excitement of losing weight to help their overall health, people don’t think about this, and it impacts them mentally and physically. This is where a plastic surgeon such as I can help.”

The day Shannon Henderson had her bariatric surgery in 2003, she weighed 301 pounds. Since the births of her two sons, now 16 and 17 years old, she’d been struggling to lose weight, seeing doctors who put her on different diets and medications to no avail.

The first month after Henderson’s surgery, she dropped 70 pounds. Back then, she says, the procedure was more invasive than it is today; part of her stomach was removed. Although she stayed healthy and experienced no other side effects, the initial weight loss was too much, too fast.

“It took a toll,” she says today. “That’s partly why I had the extra skin, because it didn’t go off slowly enough.”

Henderson’s weight-loss rate eventually stabilized. Over the following seven months, she lost another 55 pounds. Now 40, she’s still around 170.

But post-obesity life wasn’t what Henderson expected. At first, she was so excited about losing weight that she didn’t really notice the large folds of skin hanging on her legs and torso. They just felt strange. Then, in 2005, she and her husband divorced. Despite being single and slimming down, she didn’t go out much. Her appearance was holding her back.

“Even though I lost all that weight, I still had a problem of covering myself up,” she says. “I’d wear clothes that were too big in order to hide it. I was still doing some of the things I had to do when I was overweight.”

Then, last year, Henderson hurt her back at work. She blamed the extra pounds of skin burdening her smaller body. It was time to do something.

A fellow healthcare worker referred Henderson to Himansu Shah. Henderson had come across his name in her research on plastic surgeons, and he stood out for his comprehensive, minimally invasive approach. She had friends who’d undergone individual procedures, such as breast lift and augmentation, and they described weeks of painful recovery. She didn’t want that to happen to her. And it didn’t.

The weight is over

Tummy tucks and liposuction have been around for a long time, says Shah, who named his practice the Signature Institute of Aesthetic Sculpting. But technological advances mean it’s now possible to remove all the extra skin and fat from clients who’ve lost 100-400 pounds, using procedures tailored to their bodies.

Take liposuction, for instance. He offers several different approaches, from the traditional surgery, to an ultrasound-assisted version that implodes fat cells and leaves less bruising, to a needle-free option called Coolsculpting that involves freezing fat and letting it dissolve on its own. Procedures for patients who’ve undergone massive weight loss include tummy tuck, lower body lift, inner thigh lift, arm lift, breast lift, upper back lift, face lift and breast lift with augmentation.

“I limit surgery time to approximately six hours and try to complete as many procedures as possible,” Shah says. “For example, if I’m performing a lower body lift it can take 4-6 hours, so I only perform that.”

Henderson had her thighs and breasts done at the same time in April. She says she experienced none of the chest pains she’d been warned of, and despite having flesh removed from knee to hip, she had only two or three inches of sutures at the very top of her leg. “The healing time was really quick,” she says.

Recovery times vary, Shah says, but usually take two to four weeks per procedure. Transforming a patient head to toe can be done in 15 months.

Besides the time commitment, the biggest challenge for patients is financial. Procedures are cosmetic, so standard medical insurance doesn’t cover them. Some patients have to save for months or years after one procedure to pay for the next one.

‘You need to do this’

Its elective nature was one reason Henderson put off her own surgery. When she was finally on the verge of doing it, she thought of the vacation her sons wanted to take. She told them she felt guilty doing something for herself.

“No,” she remembers her younger son saying. “You need to do this. And after you have it done, you need to go out shopping, get some new clothes, go out to a bar and get a boyfriend.”

She laughs, still touched by his concern (not to mention his idea of how dating works). She plans to have the abdominoplasty next and then, possibly, an arm lift. But she has already started shopping and reviving her social life, to her kids’ delight.

“Now that I’ve had it done, I feel better about myself,” she says. “I’ve gone from not really wanting to even look at myself in the mirror and being depressed all the time to doing my hair more, putting on a little makeup, getting younger clothes. I don’t feel like I want to hide from people anymore.” Heidi Kyser

3-D mammography

Steinberg Diagnostic Medical Imaging

“I mean, just imagine what a chest X-ray was, just one picture with overlapping shadows and stuff. And then you had the CT scan, and that basically takes (pictures in) slices through the chest, so you could see everything separately… In three years, there will be no more 2-D. It’ll all be 3-D.”

— David Steinberg, managing partner of SDMI

“Life was great until I was 55,” says Deb Swan, who’s now 61. “I was in perfect health. I always worked out and lived a good lifestyle. I had been getting my mammograms since I was 40.”

It was May 2008 when Swan’s life changed. In the shower, she found a pearl-sized lump in one breast.

If you think this would send any woman running to the doctor, think again. False positive results from mammography are a common problem, particularly for those with dense breast tissue, like Swan. The National Cancer Institute reports that, on average, 10 percent of women will be recalled following breast cancer screening examinations for further testing, and only 5 of 100 women recalled will have cancer. Benign abnormalities, such as the calcifications Swan’s mammograms had been turning up year after year for a dozen years, can result in endless cycles of 6-month follow-ups that produce little more than wracked nerves and unnecessary doses of radiation.

So that May day, Swan thought, “I have a mammogram scheduled for September anyway. I’ll just wait until then and see what it says.”

Swan had a lumpectomy followed by six weeks of radiation, which stopped her cancer in its tracks. She’s been on the hormone interceptor Tamoxifen since her treatment, and continues to have mammograms every six months to help ensure she remains cancer-free.

Understandably, she’s less cavalier about visits to the radiologist now than she was before her illness.

“I don’t think about it until it’s time to go again, and then it weighs on you,” says Swan, a polished blond sales executive. She can tell the entire story of her diagnosis and treatment unflapped — with occasional humor, even. But when it comes to the aftermath, she shifts nervously in her chair.

“I do think the radiation wreaks havoc on your body,” she says. “You sleep 12 hours a day. Your hair and skin dry out. … I try not to stand in front of the microwave anymore, and if I could, I’d wear a silver suit when I fly.”

Swan is a textbook case for the argument in favor of 3-D mammograms, which, manufacturers and radiologists say, will take the mystery out of breast imaging, reducing the number of call-backs and false-positives and, consequently, the amount of radiation patients are exposed to.

Slice of life

Currently, most breast imaging is done in two dimensions. To explain the difference between 2-D and 3-D, Steinberg Diagnostic Medical Imaging COO Jerry Hartman uses this example: Imagine a loaf of bread sitting on a table. A 2-D image shows the outside of that loaf. You can take pictures from any angle, but the only way to get an idea of what’s inside is to squish it down and see what bulges out around the edges. With 3-D imaging, on the other hand, you get a picture of each slice in the loaf. If you suspect there’s a moldy piece or two, you can pull them right out of the middle of the loaf and look at them individually. If a breast is the loaf and cancer the mold, then 3-D imaging allows radiologists to see the exact “slice” where the cancer is located — without flattening the loaf.

Desert Radiologists was the first to begin offering 3-D mammography in April 2014, using Hologic’s Genius technology at the Palomino Lane and Horizon Ridge locations. SDMI’s David Steinberg says he wanted to wait for the GE SenoClaire machine that the FDA approved in August 2014, because it can take both 2-D and 3-D images with no increased radiation to the patient.

“Basically, in a screening population, only 1.5 to 2 percent of women end up having cancer,” says Steinberg. “You really don’t want to radiate people unnecessarily, because we know that, essentially, radiation is bad and can actually induce cancer.”

Steinberg also put 3-D mammography machines at all seven of his locations. “Everyone should have access to exactly the same medicine,” he says. Other than Medicare, most insurers don’t cover 3-D mammography yet, but Steinberg is confident that, by next year, most carriers will include it. The argument for the long-term cost-savings that come with early detection are simply too strong to ignore.

Don’t call us

Aanshu Shah, director of women’s imaging at Steinberg, wants to see less of women like Deb Swan, and believes her new 3-D mammography machines will help. Industry studies indicate that it identifies 40 percent more cancers in patients with dense breast tissue than 2-D, she says.

“We hope to reduce the number of call-backs and patients coming back every six months, because we can see behind that dense tissue and make a better decision at the time the patient comes in,” Shah says. “That’s going to help with patient anxiety.”

Swan’s next mammogram in October will be in 3D, and she can’t wait until she only has to be screened once a year. “This is going to help so many women who, 10-15 years ago, had to go through those needle biopsies that hurt like a stun gun,” she says. “This will save a lot more women going through cancer treatments, too. Because if it’s caught early, breast cancer is really curable.” Heidi Kyser

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